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Caesarean Section (including Enhanced Recovery)

Key Points • Classification and timings of caesarean sections are as described within this guidance • The reason for performing an emergency is recorded in the maternity notes by the person making the decision, and a consultant is included in the decision making process • Any reasons for delay in undertaking the CS are documented • All women undergoing CS are given and thromboprophylaxis (anti embolism stockings +/- low molecular weight heparin) • All women undergoing emergency caesarean section will be monitored in the appropriate location at the specified intervals. • The implications for future deliveries will be discussed with all women undergoing caesarean section prior to discharge and the discussion documented in the maternity notes

Version: 1.1 Miss Zoe Jones, consultant obstetrician and Guidelines Lead(s): gynaecologist

Miss Alex Tillett, consultant obstetrician and gynaecologist Contributors: Miss Balvinder Sagoo, consultant obstetrician and gynaecologist Lead Director/ Chief of Service: Miss Anne Deans and Clinical Ratified at: Governance Committee, 11th June 2019 Date Issued: 16th September 2019 Review Date: June 2022 Pharmaceutical dosing advice and formulary B. Joules 15th May 2019 compliance checked by: Key words: LSCS, CS, Caesarean, Operative delivery, C.Section, Vaginal cleansing This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version Control Sheet

Version Date Guideline Lead(s) Status Comment 1.0 June Z. Jones Final Joint guideline development 2019 1.1 April Z. Jones Interim Appendix (5) added for vaginal 2021 cleansing by P. Doncheva, G. David West. Approved at cross site obstetric clinical governance meeting 29th April 2021

Related Documents

Document Type Document Name Guideline Intrapartum and Postpartum Bladder Care Guideline Thromboprophylaxis and treatment of venous thromboembolism in and puerperium Guideline Anaesthesia for caesarean section Guideline Post-operative Analgesia for Caesarean Section Guideline Postpartum haemorrhage On line guide Adult Antimicrobial Guide

Abbreviations

CS Caesarean section CTG Cardiotocograph IV Intra venous LSCS Lower segment caesarean section LW Labour ward TTO To take out WHO World health organisation

V1.1 May 2021 Page 2 of 20

CONTENTS PAGE

Contents Page No

1. Elective CS 4

2. Emergency CS 5

3. Consultant attendance at CS 6

4. administration 7

5. Surgical aspects of CS 7

6. Complications occurring at CS 9

7. Additional considerations after delivery of the baby 9

8. Thromboprophylaxis 9

9. Recovery and monitoring after CS 10

10. Subsequent management on the postnatal ward and 10 community

11. Documentation 11

12. CS for praevia and morbidly adherent placenta 11

13. Enhanced recovery following CS 12

14. Communication 13

15. Implementation plan 13

16. Monitoring compliance with this guideline 13

17. References 14

Appendices 16

Category 1 Caesarean Section Flow Chart 16 Category 2 Caesarean Section Flow Chart 17 Category 3 Caesarean Section Flow Chart 18 Pathway for booking Category III Caesarean Section at WPH 19 Vaginal cleansing 20

V1.1 May 2021 Page 3 of 20 1. Elective Caesarean Section

The decision for caesarean should be made following discussion with the woman at registrar level or above. The decision should have been agreed by a consultant (unless vaginal is contraindicated and caesarean is the only option for delivery).

In general, planned caesarean section should be carried out after 39 weeks gestation to decrease the risk of neonatal respiratory morbidity and neonatal admission.

If planned caesarean section (CS) is performed prior to 39 weeks gestation, consideration should be given to the administration of 2 doses of intramuscular Dexamethasone 12mg 12- 24 hours apart or intramuscular Betamethasone 12 mg 12-24 hours apart. These should be administered between 7 days and 48 hours prior to caesarean section (unless already received earlier in pregnancy). The exception to this is dichorionic at 37 weeks gestation where steroids should not be routinely administered.

Maternal request caesarean section

• When a woman requests a CS explore, discuss and record the specific reasons for the request. • Any woman requesting a CS birth without medical or obstetric indication should be referred to be seen by the consultant following their 20 week , for counselling regarding indication, risks and benefits of this mode of birth. • When a woman requests a CS because she has about , offer referral to a healthcare professional with expertise in providing perinatal support to help her address her anxiety in a supportive manner. • Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care. • For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. • Document an agreed plan for if she attends in labour. Explain to the woman that, if labouring, a may be in her best interest especially if she is progressing or in advanced labour. Also we may not be able to facilitate the CS immediately as we work on emergency priority so she needs to be aware she may become fully dilated while awaiting an available theatre and appropriate staff. • An obstetrician unwilling to agree a CS should refer the woman to an obstetrician who will arrange the CS. Planned caesarean section compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous caesarean section

Planned caesarean section may reduce the risk of the following in women: • perineal and abdominal during birth and 3 days postpartum • injury to • early postpartum haemorrhage • obstetric shock (e.g. from haemorrhage, VTE, embolism, uterine inversion or ). Planned caesarean section may increase the risk of the following in women: • longer hospital stay • caused by postpartum haemorrhage • Planned caesarean section may increase the risk of the following in babies: • neonatal intensive care unit admission. V1.1 May 2021 Page 4 of 20 Prior to elective caesarean section:

• The date and time must have been arranged and booked via antenatal clinic (ANC) according to booking procedures individual to each hospital. • Informed, signed consent should be obtained prior to the day of . Women should be directed to watch the Frimley Health maternity online video on caesarean section and given the elective caesarean leaflet. • Ensure that all high risk patients for anaesthesia have been seen at the anaesthetic high risk ANC prior to listing them for CS. All women having an elective LSCS will see an anaesthetist at the preoperative visit to discuss the anaesthetic. If the woman has expressed a preference for other than a spinal anaesthetic, she should be referred to the obstetric anaesthetic clinic earlier in pregnancy to explore the options. • The placental site should be known, particularly in the presence of a previous - this may require an ultrasound scan prior to surgery by a fetal medicine specialist to assess for placenta accreta. • Ranitidine must be prescribed by the anaesthetic/obstetric team and patients advised on how to take this prior to surgery. • Shaving should be avoided on the day of surgery. • The fetal heart should be auscultated after the insertion of the regional anaesthetic. This may be done for at least 10 seconds so that a clear rate may be heard. This should also be documented in the medical record.

• Catheterisation will take place after the insertion of the regional anaesthetic, or prior to administration of a general anaesthetic. This will minimise the time general anaesthetic drugs can cross the placenta. • WHO checklist prior to surgery.

2. Emergency caesarean section

A decision for an emergency CS should always be discussed with the consultant on call, unless the delay in doing so would be life threatening to the woman or . Once a decision has been made to perform an emergency caesarean section, it is crucial that the urgency for the CS is documented and communicated to all team members. Classifying the urgency for delivery does not dictate the anaesthetic choice but clear communication between the obstetrician and anaesthetist as to the safest option is essential. The obstetrician making the decision should clearly document the following in the maternity notes:

• time the decision was made • indication for delivery • classification of urgency of the delivery

V1.1 May 2021 Page 5 of 20 Classification of emergency caesarean section:

Category Definition Aim for decision to delivery interval… Category 1 Immediate threat to the life of the As quickly as possible woman / fetus Category 2 Maternal or fetal compromise As quickly as possible which is not immediately life- threatening Category 3 No maternal or fetal compromise When clinically but requires early delivery appropriate for the woman and the unit. Category 4 Elective Delivery timed to suit woman and service provision

Use the following decision-to-delivery intervals to measure the overall performance of the obstetric unit: • 30 minutes for category 1 CS • both 30 and 75 minutes for category 2 CS. Use these as audit standards only and not to judge multidisciplinary team performance for any individual CS. See flowcharts in appendices 1, 2 and 3 for individual team members’ responsibilities.

3. Consultant attendance at caesarean For the procedures listed below, the consultant should attend in person or should be immediately available if the obstetrician on duty has not been assessed to be competent for the procedure in question: • • full dilatation • multiple pregnancy • known large fibroids • caesarean section <32 weeks gestation • transverse lie • more than two previous caesarean sections • fetal anomaly expected to cause difficult delivery • intrauterine fetal death • suspected/actual • previous • body mass index greater than 40

V1.1 May 2021 Page 6 of 20 4. Antibiotic administration

Offer all women prophylactic antibiotics at CS. Ideally these should be administered prior to skin incision (where practicable).

For recommended prophylaxis please refer to the “Adult Antimicrobial Guide” on the intranet.

5. Surgical aspects of CS

In general the principle pertaining to surgery outlined below should be adhered to, however deviation from this can be made at the surgeon’s discretion if clinically indicated, provided a clear reason is provided in the medical record.

Abdominal wall incision CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared with a midline incision. The transverse incision of choice should be the Joel Cohen incision (a straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and, if necessary, extended with scissors and not a knife).

Instruments for skin incision The use of separate surgical knives to incise the skin and the deeper tissues at CS is not recommended because it does not decrease wound infection.

Opening the This is usually performed by making a transverse incision on the uterus however, if there is a clinical indication a ‘DeLee’ – Vertical lower segment or classical uterine incision may be made.

Extension of the uterine incision When there is a well formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used because it reduces blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS.

Fetal laceration Women should be informed that fetal laceration may occur at up to 2% of deliveries. Routine use of Wrigley’s forceps to deliver the fetal head should be avoided.

Delayed cord clamping

Allow delayed cord clamping at all deliveries for a minimum of 2 minutes if the baby’s heart rate is greater than 100 beats per minute. Be aware of the risk of neonatal hypothermia, dry the baby and wrap with a towel during this time.

Uterotonics If there are no risk factors for postpartum haemorrhage 5 units by slow intravenous injection should be given immediately after delivery. can be used if there are risk factors for postpartum haemorrhage and if there are no contraindications/cautions (see below). Its effect lasts for 4 hours. Carbetocin 100 micrograms is administered by slow intravenous injection over 1 minute after delivery of the baby’s shoulders.

V1.1 May 2021 Page 7 of 20 If the uterus continues to be atonic and/or post-partum haemorrhage continues, further uterotonic agents may be used as per the postpartum haemorrhage guideline.

Oxytocin infusion should not be given within 4 hours of Carbetocin administration. Check the drug chart prior to prescribing further uterotonics. Contra-indications for Carbetocin: 1. Pre- / eclampsia 2. Epilepsy Cautions for Carbetocin: 1. Severe 2. 3. Hyponatraemia

Method of placental removal: At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of . It is essential that a digital examination of the uterine cavity is performed to check that the cavity is empty following the removal of the placenta.

Exteriorisation of the uterus: Intra-peritoneal repair of the uterus at CS should be undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection.

Closure of the uterus: In general the uterine incision should be sutured with two layers. The effectiveness and safety of single layer closure of the uterine incision is uncertain but may be performed if there is a clinical indication.

Closure of the : The visceral and parietal peritoneum should not be sutured at CS as this increases operating time and the need for postoperative analgesia. Routine use of a peritoneal drain should be avoided.

Closure of the abdominal wall: In the rare circumstances that a midline abdominal incision is used at CS, mass closure with slowly absorbable continuous sutures should be used because this results in fewer incisional hernias and less dehiscence than layered closure.

Closure of subcutaneous tissue: Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2cm subcutaneous fat, because it does not reduce the incidence of wound infection.

Closure of the skin: The method of closure and type of suture material can be left to the discretion of the individual taking into account the tissue type and body habitus of the patient.

V1.1 May 2021 Page 8 of 20 Wound dressing Apply a PICO dressing if the woman’s body mass index is 40 or greater, BMI 35 (or abdominal adipose tissue) with , autoimmune disease, immunosuppression, history of wound infection/healing problems.

6. Complications occurring at caesarean section

Bladder injury Should a bladder injury occur continue with delivery of the baby and suturing of the uterus. A senior urologist should be called to attend to supervise or perform the repair and arrange appropriate follow up if the surgeon is not fully competent to perform the repair themselves. An indwelling will usually be left in situ for 7-10 days on free drainage.

Impacted fetal head When caesarean section is performed at full dilatation it may be difficult to deliver the head from the . Call for senior help and communicate the problem to the multidisciplinary team. First try lowering the operating table and/or standing on a step to gain extra height. The right or left hand can be used with a straight arm to reach beneath the fetal head to flex it and bring it up out of the pelvis. The Trendelenburg may also be helpful. Glycerol trinitrate (GTN) spray or infusion may be used to induce uterine relaxation (anticipate postpartum haemorrhage). Alternative to GTN is slow intravenous salbutamol in a haemodynamically unstable patient. An experienced assistant may be able to flex and disimpact the head from below. There is a risk of causing skull fractures. An alternative is to deliver the baby by breech extraction; this may require an extension of the uterine incision (J or T shape). Call neonatologist to attend (if not already present) if there is difficulty delivering the baby.

7. Additional considerations after delivery of the baby

Umbilical vessel pH measurement

Umbilical vessel pH levels should be taken after all category 1-3 CS and category 4 CS if there is suspected fetal compromise or a breech presentation. This allows review of fetal wellbeing and guides ongoing care of the baby. These paired cord gas samples should be taken as soon as reasonably possible after delivery of the placenta.

Thermal care for babies born by CS

Babies born by CS are more likely to have a lower temperature, and thermal care should be in accordance with good practice for thermal care of the newborn baby.

8. Thromboprophylaxis

Give according to the Trust guideline “Thromboprophylaxis and treatment of venous thromboembolism in pregnancy and puerperium”. When indicated, the thromboprophylactic dose of LMWH should be given 4 hours after spinal anaesthetic or removal of epidural catheter and when there is no immediate risk of postpartum haemorrhage.

V1.1 May 2021 Page 9 of 20 9. Recovery and monitoring after CS

All women are transferred back to labour ward or recovery for the immediate recovery period after CS until stable enough for transfer to the postnatal ward.

During the recovery period from anaesthesia regular observations should be performed including:

• BP and Pulse • Temperature • Respiratory rate • Oxygen saturation • Level of sedation • or blood loss • Abdominal incision site • Uterine size and tone • Fluid balance • Adequacy of analgesia

The epidural catheter should be removed from the patient before transfer to postnatal ward.

Observations should be taken and recorded on MEOWS chart: • On admission to the postnatal ward • Every 30 mins for 2 hrs • Every 60 minutes for the following 2 hours (until 4 hrs following PN ward admission) • Every 4 hrs thereafter.

During the recovery period, provided the mother is conscious and stable encourage early skin-to-skin contact between the woman and her baby and offer support to initiate .

See “Anaesthesia for caesarean section” for guidance on post-operative analgesia.

10. Subsequent management on the postnatal ward & Community

Eating and drinking after CS:

Women who are recovering well after CS and who do not have complications can eat and drink when they feel hungry or thirsty. For patients who have had a complicated surgical procedure, medical personnel should establish the return of bowel sounds before feeding the patient.

Urinary catheter removal after CS:

See “Intrapartum and Postpartum Bladder Care” guideline. Note that after emergency CS, the urinary catheter should stay in for 12 hours post-operatively, unless stated otherwise.

V1.1 May 2021 Page 10 of 20 Debriefing the patient:

Prior to discharge from hospital the woman should be given the opportunity to discuss with healthcare professionals the events surrounding the delivery and the reasons for the CS. They should also be provided with information about birth options for any future pregnancies.

Women will be reviewed by an anaesthetist the day after their anaesthetic.

Postnatal wound care

Remove “Mefilm” dressing on day 1 or 2, “Mepilex Border” wound dressing after 5 days, PICO dressing after 7 days. Follow surgeon’s instructions for the removal of non-absorbable suture material.

11. Documentation

The operative details should be recorded on IQUtopia (WPH) or Euroking (FPH). These should be printed, signed and filed in the patient medical record.

Any additional information pertinent to the case should be recorded in the contemporaneous medical record.

Recommendations for immediate post-operative management should be clearly recorded and communicated with the Midwife looking after the patient.

Recommendations for future pregnancies, taking into account the reason for caesarean section and the progress of labour, should also be made in the maternity notes. These recommendations should then also be discussed with the mother prior to discharge.

12. Caesarean section for placenta praevia and morbidly adherent placenta

Diagnosis Possibility of a morbidly adherent placenta should be suspected in a woman with a low lying placenta who has had a previous caesarean section or other incision on the uterus. Diagnosis should be made with Doppler ultrasound. If the diagnosis remains unclear, MRI may be discussed. The unknown long term risks of MRI for the fetus remain unclear and women should be made aware of this, although it is thought to be safe.

Pre-operative planning Advanced manoeuvres to obtain haemostasis should also be discussed and consented for prior to surgery such as cell salvage, balloon tamponade, interventional radiology techniques, additional sutures and hysterectomy.

When performing a CS for women suspected to have morbidly adherent placenta, ensure that: • a consultant obstetrician and a consultant anaesthetist are present • a paediatrician is present • a senior haematologist is available for advice • a critical care bed is available • sufficient cross-matched blood and blood products are readily available

V1.1 May 2021 Page 11 of 20 • planned delivery may involve cell salvage and the request for interventional radiology which must be made by prior arrangement.

Also refer to Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline No. 27 on the Management of placenta praevia, placenta praevia accreta and : diagnosis and management at: http://www.rcog.org.uk/files/rcog-corp/GTG27PlacentaPraeviaJanuary2011.pdf

13. Enhanced recovery following caesarean

Background The core ethos of enhanced recovery is to speed up a patient’s recovery after surgery and improve patient outcomes, with associated benefits for staff and healthcare systems. The aim of enhanced recovery is to optimise multiple aspects of patient care to improve recovery and so facilitate earlier discharge.

Inclusion criteria All elective caesarean sections unless excluded by the surgeon. Some women who have a category 3 CS may be suitable for the enhanced recovery programme and this should be considered on an individual basis.

Antenatal Elective Caesarean section agreed: Obstetrician to discuss early normalisation and expectation regarding discharge.

Preoperative appointment: midwife/ anaesthetist Discuss pain relief, the possibility of nausea and vomiting, catheter removal and mobilisation. Reaffirm expectation regarding normality and discharge.

On the day of surgery Midwife to discuss expectations around normalisation (ie feeding, catheter removal) / mobilisation / discharge. Theatre team to inform the ward of delays to the list to allow hydration (IV/Oral) if CS is delayed.

Anaesthetist Regional anaesthesia with intrathecal opioids Consider TAP (transverse abdominis plane) block after a GA. Small amount of intravenous fluids at CS. An under patient heating blanket should be used. Anti-emetics to be administered routinely IV down before transfer to recovery.

Obstetrician SHO to complete discharge letter in theatre.

Midwife Facilitate skin to skin contact in theatre because early skin-to-skin contact improves breastfeeding success.

In recovery Baby to be fed in recovery. Encourage the woman to drink in recovery.

V1.1 May 2021 Page 12 of 20 Patient on the ward Encourage to eat and drink normally. Regular analgesia and patient allocated oral opioids (oramorph regime) Offer regular analgesia as described in the “Post-operative Analgesia for Caesarean Section” guideline. Review after approximately 4- 6 hours to assess spinal has worn off (can be done sooner at patient request) Remove catheter 6 hours after surgery if the spinal has worn off enough for the woman to get up and walk to the toilet. Patient out of bed and in a chair with baby.

Day 1 Early and obstetric reviews NIPE (newborn infant physical examination) and hearing examination to be completed Ensure any TTOs which may be needed are available.

Subsequent time in hospital The aim should be to move the patient along towards fit for discharge criteria and then discharge. It is important to recognise that some patients will have complications which may reduce their movement along this pathway but will need constant reassessing of their situation. Patients may be discharged at different times depending on their individual needs and progress along this pathway.

14. Communication If there are communication issues (e.g., English as a second language, learning difficulties, blindness/partial sightedness, deafness) staff will take appropriate measures to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them.

15. Implementation Plan The latest ratified version of this guidance will be posted on the Trust's Intranet site for all members of staff to view. A notice will be placed on the intranet and the ‘In Touch’ newsletter informing Maternity staff of version changes. New members of Maternity staff will be signposted to how to find and access this guidance at Induction.

16. Monitoring compliance with this guideline Audit will be as per the maternity annual audit plan

Auditable standards for enhanced recovery Met criteria for inclusion in the enhanced recovery programme. Urinary catheter removed six hours after delivery.

Auditable standards: • Classification and timings of caesarean sections are as described within this guidance • The reason for performing an emergency caesarean section is recorded in the maternity notes by the person making the decision, and a consultant is included in the decision making process • Any reasons for delay in undertaking the CS are documented • All women undergoing CS are given antibiotics and thromboprophylaxis (anti embolism stockings +/- low molecular weight heparin)

V1.1 May 2021 Page 13 of 20 • All women undergoing emergency caesarean section will be monitored in the appropriate location at the specified intervals. • The implications for future deliveries will be discussed with all women undergoing caesarean section prior to discharge and the discussion documented in the maternity notes

This will be achieved through: • Continuous audit of all caesarean sections presented at monthly academic half days. • Daily reviews of all emergency caesarean sections performed in the last 24 hours. • Monthly report and discussions of issues affecting caesarean section rates at labour ward forum and action plans developed as necessary. • Quarterly report to the obstetric clinical governance group to monitor implementation and completion of action plans.

17. References

NICE. (2011) Clinical Guideline 132. Caesarean section. National Institute for Clinical Excellence, London.

Stutchfield P, Whitaker R, Russell I; Antenatal Steroids for Term Elective Caesarean Section (ASTECS) Research Team. Antenatal betamethasone and incidence of neonatal respiratory distress after elective Caesarean section: pragmatic randomised trial. BMJ 2005;331:662.

Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, MennutiM. A randomized trial of early hospital discharge and home follow-up of women having cesarean birth. Obstet Gynecol 1994;84:832–8.

Chiong Tan P, Jin Norazilah M, Zawiah Omar S. Hospital discharge on the first compared with the second day after a planned cesarean delivery. Obstet Gynecol 2012;120:1273–82.

Dickinson, J.E. (1999) Caesarean section. In: High Risk Pregnancy. Management Options, edited by D.K. James, P.J. Steer, C.P.Weiner, and B. Gonik, London: W.B Saunders Company Ltd, p. 1217-1229.

Harper CM, Alexander R. Hypothermia and .Anaesthesia 2006;61:612.

Hui CK, Huang CH, Lin CJ, Lau HP, Chan WH, Yeh HM. A randomised double-blind controlled study evaluating the hypothermic effect of 150 micrograms morphine during spinal anaesthesia for caesarean section. Anaesthesia 2006;61:29–31.

Hutton EK, Hassan ES. Late vs early clamping of the in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA 2007;297:1241–52.

Lucas DN, Gough KL. Enhanced recovery in obstetrics – a new frontier? Int J Obstet Anesth 2013;22:92–5.

McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2008;4:CD004074.

Mackenzie, I.Z, Cooke, I.E. (2001) Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" Caesarean section. BMJ 322 :1334-1335.

V1.1 May 2021 Page 14 of 20

Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012;5:CD003519.

Niranjan N, Bolton T, Berry C. Enhanced recovery after surgery –current trends in perioperative care. Update Anaesth 2010;26: 18–23.

NHS Enhanced Recovery Partnership. Fulfilling the potential: a better journey for patients and a better deal for the NHS. http://www.improvement.nhs.uk/documents/er_better_journey.pdf

NHS Institution for innovation and improvement. Commissioning for quality and innovation (CQUIN) payment framework. http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin

Thomas et al (2004) National cross sectional survey to determine whether the decision to delivery interval is critical in emergency Caesarean section. BMJ 328 (7441):665.

Brock, M, Greenwood, C, et al. (2009) Oxford Radcliffe Hospitals NHS Trust. Delivery Suite Guidelines. Version 5.0 : p. 70 -73. Prior E, Santhakumaran S, Gale C, Philipps LH,Modi N, HydeMJ. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. AmJClin Nutr 2012;95:1113–35. Royal College of Obstetricians and Gynaecologists. Reducing the risk of Thrombosis and Embolism during pregnancy and the puerperium. Green-top Guideline No. 37a. London: RCOG; 2009 http://www.rcog.org.uk/files/rcog-corp/GTG37aReducingRiskThrombosis.pdf Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. Green-top Guideline No. 52. London: RCOG; 2009 http://www.rcog.org.uk/files/rcog-corp/GT52PostpartumHaemorrhage0411.pdf Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29: 434–40. Vickers R, Das B, Machineni V. Enhanced recovery in obstetrics. Int J Obstet Anesth 2013;22:S13. Wee M, Brown H, Reynolds F. The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections: implications for the anaesthetist. Int J Obstet Anesth 2005;14:147– 58.

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APPENDIX 1. CATEGORY 1 CAESAREAN SECTION FLOW CHART OBSTETRICIAN COORDINATOR MIDWIFE SHO ANAESTHETIST THEATRE STAFF • Decision made for LSCS • Calls 2222 to • Stays with woman . Offers • Receives 2222 • Prepare theatre following discussion with announce assistance as call, moves to woman “category 1 • Prepares woman for required to theatre • Category 1 • Informs LW coordinator of caesarean theatre – asks her prepare immediately section decision - stating ‘category section (and to adopt left lateral woman for patient will be 1 caesarean section’ location of position surgery (e.g. • Sees woman brought • Informs consultant but may patient)” via with blood and reviews straight to leave this to expedite emergency bleep • Goes to theatre with samples) anaesthetic theatre by LW transfer to theatre* system woman within 5 needs in staff • Initiates intrapartum fetal minutes of decision . Scrubs to theatre measures if • *May be required assist • Ensure WHO doesn’t delay transfer to to contact • On arrival in theatre surgeon • Inserts IV checklist theatre – consider consultant on reconnects CTG cannula and completed terbutaline behalf of registrar takes blood if • Obtains consent (written or in ‘extreme’ • Catheterisation and not already verbal) emergency shave taken for FBC, • Continues to monitor group & save maternal and fetal condition • Ensures that the • Informs for any change in partner(s) paediatrician of • Agrees mode categorisation remaining on LW clinical of anaesthetic • Aim for theatre transfer is/are kept history/indications with within 5 minutes of informed of for caesarean obstetrician decision progress and and woman • Discusses mode of offered ongoing anaesthetic with support • Completes anaesthetist “Sign In” on • Completes “Time Out” on WHO checklist WHO checklist prior to caesarean

V1.1 May 2021 Page 16 of 20

APPENDIX 2. CATEGORY 2 CAESAREAN SECTION FLOW CHART OBSTETRICIAN COORDINATOR MIDWIFE SHO ANAESTHETIST THEATRE • Decision made for • Calls 2222 to • Stays with the woman . Offers • Receives 2222 call STAFF caesarean following announce • Prepares woman for assistance • Sees woman and • Prepare discussion with woman “category 2 theatre: gown & pre-op as required reviews theatre and documented in to prepare caesarean section check list anaesthetic needs notes • Places woman on woman for • Aim for theatre • Send for (and location of • Takes into account canvas in left lateral surgery within 10 mins of woman 5 other patient needs and patient)” via position (e.g. with decision minutes need to escalate to emergency bleep • Ensures effective blood • In theatre: after being other staff system communication samples) completes notified of • Informs consultant if • Organises partner to anaesthetic category 2 applicable change . Goes to assessment if this caesarean • Informs LW coordinator • Offers assistance • Goes to theatre with theatre to has not been done section scrub and of decision - stating to midwife as woman. Aim for theatre prior to transfer required assist • • Ensure ‘category 2 caesarean transfer with 10 mins of Inserts IV cannula section’ obstetrician and takes blood if ‘WHO decision • Obtains informed • Ensures any birth not already taken checklist’ written consent partner remaining for FBC, group & completed • On arrival in theatre • Continues to monitor on LW is offered save reconnects CTG maternal and fetal ongoing support • Agrees mode of

condition for any anaesthetic with • Catheterisation and change in obstetric registrar shave categorisation and woman

• Goes to theatre with • Completes “Sign • Informs paediatrician of woman. Aim for theatre clinical In” on WHO transfer with 10 mins history/indications for checklist of decision caesarean • Considers fetal resuscitation measures • Completes “Time Out” on WHO checklist prior to caesarean

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APPENDIX 3: CATEGORY 3 CAESAREAN SECTION FLOW CHART OBSTETRICIAN COORDINATOR MIDWIFE SHO ANAESTHETIST THEATRE STAFF

• Decision made for LSCS • Informs theatre of • Continues to offer . Attends • Receives call • Prepare theatre following discussion with category 3 caesarean one-to-one care theatre when for category 3 woman and consultant section. At FPH: • Prepares woman the woman is caesarean • Send for and documented in the complete theatre for theatre: gown ready for woman as notes booking form, WPH: & pre-op check list surgery • Sees woman agreed with • Takes into account other see appendix 4 • Places woman on and reviews labour ward patient needs • Advises theatre canvas in left . Offers anaesthetic coordinator • Informs LW coordinator of coordinator of lateral position assistance as needs decision - stating category anticipated timing of • Ensures effective required • Ensure ‘WHO 3 caesarean section. delivery communication • Inserts IV checklist’ • Informs anaesthetic . Scrubs to cannula and completed registrar • Informs obstetric • Organises partner assist surgeon takes blood if • MDT discussion regarding SHO to change not already timing of procedure taken for FBC, • Notifies neonatal • Goes to theatre group & save • Obtains informed, written unit & postnatal with woman if maternity consent ward as appropriate staff have • Continues to monitor • On arrival in been maternal and fetal • Offers assistance to theatre reconnects unsuccessful condition for any change midwife as required CTG if required in categorisation • Agrees mode • Ensures any birth • Catheterisation of anaesthetic • Attends theatre when the partner remaining and shave with woman woman is ready for on labour ward is • Informs surgery offered ongoing paediatrician of • Completes • Completes “Time Out” on support clinical “Sign In” on WHO checklist prior to history/indications WHO checklist caesarean for caesarean

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APPENDIX 4 – PATHWAY FOR BOOKING CATEGORY 3 CAESAREAN SECTION AT WPH

Consultant decision for Category III Caesarean Section

LW Coordinator & LW Consultant to be consulted if c/s is feasible within 6 hours from decision

LW able to If unable to accommodate accommodate or unsuitable to be done within 6 hours

Preparation for Category III Patient to be either: Caesarean Section within 6 hours 1. Booked on next available 1. Patient to be made NBM elective Caesarean Section list 2. Administer Ranitidine organised by consultant booking grade 3 (if list full consider 3. Move to Labour Ward 4. Inform anaesthetics rescheduling a booked Caesarean Section who is low 5. Urgent FBC, G&S risk e.g. a maternal request on 6. Consent discussion with Miss Bal Sagoo 7. Book on IQUtopia and/or Kathy Friend)

2. If sufficient concerns of feto-maternal wellbeing, to escalate to Category II Caesarean Section.

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APPENDIX 5: VAGINAL CLEANSING

1. Background

World Health Organisation recommends vaginal cleansing with povidone-iodine immediately before Caesarean section1. The evidence2 indicates an overall reduction of post-Caesarean endometritis by 59%. The risk decreases by 65% in emergency Caesarean sections and by 14% in elective Caesarean sections. Additionally, there is a 36% decrease in post-operative fever, 38% decrease in post-operative wound infection and a 54% decrease in composite wound complications. Vaginal cleansing solutions, such as and povidone‐iodine, have very few side effects in general, with low rates of noted or irritation symptoms2.

2. Method of vaginal cleansing ◦ Vaginal cleansing with chlorhexidine solution should be performed before elective and emergency caesarean sections at the time of urinary catheter insertion in theatre. ◦ Use a swab soaked in chlorhexidine to clean in the following order: the , and . ◦ Using a sponge holder and mounted swab soaked in chlorhexidine, insert once into the vagina and rotate for 30 seconds. ◦ Remove from the vagina and count swabs. ◦ Proceed with urinary catheter insertion. ◦ Document on IQ/patients notes that vaginal cleansing has been performed.

3. Contraindications ◦ Category 1 emergency Caesarean sections due to time restriction (cord prolapse, abruption, uterine rupture) ◦ Patient not consenting to the procedure

4. Auditable standards ◦ Verbal consent has been obtained and documented. ◦ Post-Caesarean infection rate (endometritis, post-op fever and wound infection). ◦ Allergies/adverse reactions.

5. References 1. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections

2. Haas DM, Morgan S, Contreras K, Kimball S. Vaginal preparation with solution before caesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2020, Issue 4.

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